Welcome to the May issue of HOC. In it, you’ll find Part 1 of our coverage of the 5th World Health Care Congress (WHCC) in Washington DC, as well as some further pieces from the WHCC in Berlin. Regular contributor Mary Gabb discusses healthcare funding, and your editor muses on meetings – and how they might be briefer, better, and rarer.
David Woods
“Medicine being a compendium of successive and contradictory mistakes of
medical practitioners, when we summon the wisest of them to our aid, the
chances are that we may be relying on a scientific truth the error of which
will be recognized in a few years’ time”
Marcel Proust, (1871–1922)
Defining the healthcare debate in the US
By Mary Gabb (mary.gabb@rxcomms.com)
Nowadays, healthcare is hotly debated, and not just for US presidential candidates. Virtually every western country is now grappling with the challenge of how to pay for healthcare for its citizens. The US has garnered much attention in this debate, as it is the only western country that does not have universal healthcare coverage, yet it spends 16% of its GDP on healthcare with equivalent (and in some cases, poorer) outcomes.
Part of the debate centres on whether healthcare is a basic human right: is the US morally wrong for not providing universal coverage or simply shooting itself in the collective foot because sick people ultimately cost society even more money? But there is another, more concrete aspect to the healthcare debate – cost. Who is going to pay for it?
Most of the increasing costs in healthcare in recent years are from technological advances, yet the debate often points directly to the pharmaceutical industry. It is not illegal for pharmaceutical manufacturers to make profits. It is not illegal for them to make big profits. So, why does it bother some people so much, for example, when we hear reports that pharma spends more of its budget on advertising than R&D?
It bothers them because it is not possible to discuss healthcare in strictly dollars and cents (or pounds and pence), as we do with other government programmes, such as maintaining roads or postal services, or even programmes that affect us more personally, such as education and pensions. Healthcare is so personal because it affects our very survival. We have a deeply vested interest in its outcomes. And discussing healthcare rationing or cuts to funding tests our survival instincts, because our very existence is at stake. Hence, we come to view it as a right.
Moreover, in an effort to quantify cost-benefit discussions of healthcare, we demand scientifically-rigorous proof that the interventions work – evidence-based medicine (EBM). But medicine is not an exact science and EBM disregards the art of medicine – the side of medicine that takes into account the individual patient and his/her personal life story and circumstances. Evidence-based medicine tries to apply a one-size-fits-all solution to every single human being, the most complex creatures on this planet.
Governments, healthcare providers, insurers, and patients all turn to health economists for answers to these complex questions, and health economists have tried to balance the moral argument of a basic human right and the strictly economic argument of monetary value with concepts such as human capital and quality-adjusted life year.
In the end, healthcare is neither a basic human right nor a strictly cost issue; it lies somewhere in the middle. For societies that can afford a universal healthcare plan, it should be provided. The question for the US is, with a $9.5 trillion debt and no end in the foreseeable future to a costly war, can we afford it? And if we can, it should not be a standardised federal programme. Rather, it should be state-run programme, so that EBM can be adapted to more local needs.
Meeting the challenge of meetings
By David Woods (david.woods@rxcomms.com)
A meeting, according to my dictionary, is an assembly of persons for a specific purpose. Perhaps a more whimsical definition might be that of an anonymous author who said that a meeting is an event where minutes are taken and hours wasted.
Why is it, I wonder, that meetings have assumed such prevalence in the corporate world? Do they meet some social need? Do they provide an opportunity to strut one's stuff in front of one's peers?
Jim Buckmaster, the chief executive of Craigslist, the Internet classified advertising company, told the Financial Times recently: “I've always found them to be at best unproductive and boring, and at worst toxic and destructive. The people who want to show off, do; the brown nosers brown nose; everyone else wastes their time; I also think the larger the meeting, the worse it is.”
Are there ways of meeting the challenge of making meetings more productive, objective, briefer, and even enjoyable? Several formulas have their proponents: some have proposed that all meetings be conducted standing up; others have argued for rigid time limits, not only for the entire meeting but for each speaker; still others call for a stern – but respected – ringmaster to take charge and squash any grandstanding or waffling. There are those who favour a ban Monday or Friday meetings, while the more sadistic suggest holding them only on Fridays at 4:15pm. And the more anarchic argue for simply walking out of meetings that seem irrelevant or unproductive.
And there’s the issue of where to hold the meeting. The boss’s office might be a place too intimidating or inhibiting; the conference room could present issues of who sits where; and the teleconference is surely just too impersonal and ethereal. Well, you could have an offsite meeting, sometimes called a retreat – a word that always struck me as inappropriate for an event designed to bring about any measure of progress. Although going out of the office does lend gravity to the proceedings.
So let’s look at some possible ways of meeting the challenge of meetings:
- Productive: Limit the number of participants; have a clearcut agenda with equally transparent objectives, and a chairperson who will state that agenda at the outset, make sure everyone sticks to it, and at the conclusion summarise the decisions reached and who’s going to fulfil them.
- Objective: Make sure everyone present is a tabula rasa... with no preconceived notions, or axes to grind.
- Briefer: Limit the time to 60 minutes with no breaks and no distractions – cell phones, reading emails on Blackberries, surfing the web, food.
- Enjoyable: Well, three out of four ain’t bad; although one might argue that this challenge might be met if the others are. And anyway, meetings can give rise to mordant, weltschmerz humour, as in ‘they called a meeting on apathy but nobody showed up;’ or ‘they called one on procrastination but everyone was late.’
We might even get away from the notion propounded by the eminent Canadian economist, John Kenneth Galbraith that “meetings are indispensable if you don’t want to get anything done.” Too dismal, John. There may be some good – and some to-do’s – to be wrested from meetings if they’re handled properly.
“Nature had not intended mankind to work from eight in the morning until midnight without that refreshment
of blessed oblivion which, even if it lasts only twenty minutes, is sufficient to renew all the vital forces.”
Winston Churchill, on the subject of naps (1874–1965)
Alcohol and global warming – what’s the common theme?
By Ruth Whittington (ruth.whittington@rxcomms.com)
According to Michael Wilks, Chairman of the Standing Committee of European Doctors (CPME; an organisation facing the challenges of its current 2 million doctors in 27 countries being expanded by an ever-growing EU), these are two major influences of healthcare provision. The CPME has subcommittees that deal with four areas concerning doctors at an EU level:
- the organisation of healthcare
- prevention of disease
- ethics of medicine
- training.
These subcommittees report to the Board, and the CPME also comprises a Secretariat, Executive Committee and General Assembly. The mandate of the CPME is simple; to improve the healthcare for patients, and Wilks is of the opinion that this can only be achieved by increasing the interaction with patients. In his talk at the World Healthcare Congress, Wilks discussed four issues that will influence the relationship between patients and their doctors – and therefore the quality of the healthcare they receive.
Healthcare policies
Wilks posed the question: do healthcare policies really work? He presented evidence to indicate that no, they don’t – or at least, not in isolation. Evidence suggests that the only thing really influencing healthcare was wealth.
E-Health
The old style of healthcare with a single doctor-patient relationship relied on manual records, doctor’s memory, the familiarity with the patient and a continuity of care. Now the multifunctional team means that the patient is likely to see more than one doctor at a large clinical practice, and that a nurse practitioner may also be a participant in the patient’s healthcare. The coming of an electronic patient record, while perhaps improving the communication between the different healthcare providers, will only encourage the likelihood of more participants; the benefits offered by continuity and familiarity will be lost. Wilks posed the question: do we know what this will mean in terms of the quality of the relationship between patient and doctor? He said that as long as the patient was the focus of interaction and not the electronic record itself then the change may be beneficial.
Alcohol
Wilks talked about the obvious dangers of tobacco and poor nutrition (both excess and deficits) but talked about the interesting effect of alcohol – positive in moderation and problematic in excess. He pointed out that there are different hazards with alcohol in different age groups – that young men aged 18–24 appear to have a linear relationship between alcohol and health hazard because the main risk in this instance is the acute effects of alcohol – increased risk of driving accidents, violence and harm due to the intoxication. The role of the doctor in this case is difficult; it is hard to persuade this age group to decrease their intake. This is a different relationship than the one of typically older age groups who drink heavily – to a certain point the relationship between alcohol intake and hazard is linear, but beyond a particular limit the damage becomes disproportionately large for a small increment in intake. In these instances the doctor must focus on moving the patient to an intake below the change.
Global warming
Wilks spoke about the change in ice cores indicating without doubt that we are on an exponential curve for global warming – he felt the change was inevitable given the current climate. He said that the increased temperatures would lead to changing patterns in infectious diseases, and heat-related mortality would increase dramatically. In 2025, given the current rate of change, that the average temperature in the EU would be the same as the most extreme temperature experienced in France in the last heatwave, that killed a record number of people from heat-related problems. Increased drought, more frequent and more serious natural disasters (tsunamis etc) will again alter the doctor’s workload and relationship to his or her patients. He pointed out that we currently have all the technology we need to prevent this happening, and that 1% of current GDP would at least stabilise the climatic change; but this is unlikely to happen. It was a sobering and intriguing perspective on an ecological problem that appeared (at first) to be unrelated to healthcare.
“Why did you start, what did you do, what answer did you get, and what does it mean anyway?
This seems to me to be a logical order for a scientific paper”
Sir Austin Bradford Hill (1897–1991) – British epidemiologist and statistician; pioneer of the randomised clinical trial
Fifth Annual World Health Care Congress
By David Woods (david.woods@rxcomms.com)
The 1500 registrants to the Fifth Annual World Health Care Congress in Washington, DC April 20–23 were treated to 10 keynote addresses and more than 60 breakout sessions. One of the opening keynotes was about the current US presidential debate on healthcare. Speaking on behalf of Senator Barack Obama, Congressman Jim Cooper of Tennessee said that his candidate wanted to see enhanced competition between rival health plans. Speaking for Senator John McCain, Thomas Miller, a fellow of the American enterprise Institute, said that McCain wanted to see reform of the payment system and engagement of patients as active participants in their own health. Payment reform, McCain believes, will be spurred by a generous refundable tax credits.
And for Hillary Rodham Clinton, Chris Jennings, president of Jennings Inc., and a former senior White House health advisor, asked how can we leave 47 million uninsured in the richest country in the world? Everyone has to be in the system, he said.
Reacting to these expressions, George Halvorson, CEO of Kaiser Permanente, said that the current presidential debate is the most sophisticated ever. “They understand the issues.” He added though that the United States should be less inward looking and seek solutions elsewhere: for example, he said, in Germany, employees are mandated to buy insurance and insurers to provide coverage; and there are 400 competing health plans.
And George Schultz, a former US Secretary of State, warned of the prospect of intergenerational tension. He also called for a new emphasis on basic research which is vital, he said, and yet we are flatlining the National Institutes of Health. Basic research is what led to penicillin, he said; yet pharmaceutical companies still focus on applied research. He called for a greater emphasis on education and information, noting that many of the 700,000 stroke cases annually could be prevented if only people had their blood pressure checked. Halvorson stated that we’ll be so much smarter in a couple of years because of advances in genetics and that we’ll look back on today as the dark ages.
A recurring theme at the Congress was that of so-called “medical homes.” Humphrey Taylor, chairman of the Harris Poll, defined these as a better way of delivering primary care in which an adult has both a regular doctor and a place of care... and continuous contact with both. Dr. Shane Reti, a Maori GP from New Zealand opened his presentation on the subject by singing a Maori song of welcome. Medical homes, he said, are all about doing the right thing in the right way. “Evidence-based medicine trumps opinion,” he said, and medical homes are all about Whanau Ora, the Maori phrase for family care; moreover, they are integrated, coherent, IT adopting, and geared for feedback and guidance.
In a panel on achieving accountable care, Elliot S. Fisher, MD, of Dartmouth Medical School, pointed out the huge differences in standards across communities, noting that the highest spending doesn't necessarily get better results... and physicians and hospitals need to be rewarded for better care, not for more care. Mark McClellan of the Brookings Institute and a former head of the Centers for Medicare and Medicaid, spoke of how the CMS is moving towards pay for performance and is looking – again that phrase – to the concept of medical homes. He also noted that the shift to generic drugs in Medicare has gone from 50% to 70%.
In a keynote address titled ‘A call to action from employers,’ Stephen A. Burd, CEO of Safeway, stated that prevention and behaviour are the gold standards of healthcare reform. Noting that 70% of healthcare costs are driven by behaviour, 74% of all costs are for chronic conditions, and 80% of cardiac disease is preventable, he described the Safeway model of behaviour related incentives. The company subsidises healthy meals in its cafeteria but won’t foot the bill for hamburgers and fries.
Isn't this a bit big brother-ish, asked moderator David Noonan, senior editor for health and medicine at Newsweek. “Can you fire the obese or the smoker?” Burd replied that the Safeway campus is smoke-free, and that the company pays for smoking cessation programmes and for nutritional counselling for the overweight.
In a panel on an electronic health records, participants believed that these will be driven by genetic information... and that for patients to be effective partners in healthcare all the information needs to be in one place under the consumer’s control. So far as ratings of doctors and hospitals are concerned, the issue isn’t what is the best hospital in, say, Birmingham, but which is the best one for a 44-year-old woman with mitral valve prolapse. These panellists echoed many other presenters to the effect that patients need to be educated from a very early age to be literate and aware of both their own and general healthcare issues.
In a discussion of pharma and biotech, Dr Joshua Ofman of Amgen noted that while pharmaceutical costs represent only about 12% of total spending on healthcare, drug innovation has added tremendous improvement in healthcare overall. Even so, he said the value of drug innovation is still not fully recognized today; moreover, he believes, benefits to society accrue long after patent expiry, citing as an example Eli Lilly's Prozac. Sir Michael Rawlins, head of NICE, said that UK health expenditures as a percentage of GDP had risen from 6% to 9% just in the past two or three years. He said that fitness for purpose is the principal criterion for NICE evaluations, but the idea is to balance efficiency with fairness, and to seek value for money. Sir Michael also noted that “randomised clinical trials should not be worshiped.”
Medical homes cropped up again during a keynote address that was supposed to be on the impact of value-based purchasing and next steps for reimbursement, but turned out to be more of a free-for-all on health policy. John Tooker, EVP of the American College of Physicians, called for a strong reemphasis on primary care, involving the patient in comprehensive, continuous, community, coordinated care. Andrew Webber, of the National Business Coalition on Health, agreed, saying that we focus too much on specialty care instead of primary care and prevention. As with others, he called for pay for performance and consumer empowerment. Uwe Reinhardt, the noted Princeton professor and healthcare policy guru, said that healthcare IT should capture every doctor order for every patient. As for payment reform, he suggested bundling treatments and paying for the overall treatment. Asked about a possible model on which to base future US healthcare, Dr. Reinhardt suggested that Switzerland and Holland would be pretty good models.
Rosemarie Greco a former president of CoreStates Bank, the 12th largest in the United States, and now head of the Pennsylvania Governor's Office of Healthcare Reform, estimated that the US spends some $3.7 billion in avoidable hospital charges... and fellow panellist Dr. Richard Migliori, chief healthcare officer of United Health Group, also called for patient centred medical homes.
HOC will follow up with interviews of some of the presenters at the Congress, including Dr Joshua Ofman of Amgen, Stanley Blaylock, CEO of Walgreens, and Rosemarie Greco.
Abstract submission deadlines
Please note that dates were correct at time of sending this email; HOC cannot be responsible for any amendments.
Submit |
Meeting |
Abbrev. |
Therapeutic |
Meeting date |
|---|---|---|---|---|
| 19 May 08 | Interscience Conference on Antimicrobial Agents and Chemotherapy, Washington, DC, USA www.icaacidsa2008.org/ |
ICAAC | Anti-infectives | 25–28 Oct 08 |
| 26 May 08 | European Gastroenterology Week |
UEGW | Gastro- entorology |
18–22 Oct 08 |
| 30 May 08 | Asian Pacific League of Association for Rheumatology Pacifico Yokohama, Japan www.aplar2008.com/ |
APLAR | Musculo- skeletal |
23–27 Sep 08 |
| 2 Jun 08 | IOF World Congress on Osteoporosis Bangkok, Thailand www.iofbonehealth.org/wco/2008/ |
IOF | Musculo- skeletal |
3–7 Dec 08 |
| 6 Jun 08 | American Academy of Dermatology Annual Meeting San Fransisco, CA, USA www.aad.org/meetings/annual/AM2009/ |
AAD | Dermatology | 6–10 Mar 08 |
| 6 Jun 08 | Annual Scientific Meeting of the American Geriatrics Society Chicago, IL, USA www.americangeriatrics.org/news/meeting/2009/call_proposals.shtml |
AGS | General | 29 Apr – 3 May 08 |
| 13 Jun 08 | Annual Meeting of the American College of Clinical Pharmacy Louisville, Kentucky, USA www.accp.com |
ACCP | General | 19–22 Oct 08 |
| 23 Jun 08 | International Society of Pharmacoeconomics and Outcomes Research European Meeting, Athens, Greece www.ispor.org |
ISPOR (Eur) | Health economics |
8–11 Nov 08 |
| 27 Jun 08 | European Society of Clinical Pharmacy |
ESCP | General | 22–24 Oct 08 |
Health economics for non-health economists
Rx Communications in partnership with Greenflint have published a series of beginner’s guides which put the core principles of health economics into language which people can understand. Beginner’s guides currently in the pipeline are:
The booklets are available in a generic format or they can be customised and branded to suit your organisation and its culture. In addition to the literature, Rx Communications also provides an interactive training module to work simultaneously with the booklets to support the learning process, and this can be situated on your internet, intranet or on a branded CD-ROM or flash drive. For more information or a media pack, please contact duncan.dibble@rxcomms.com ; alternatively click here to view an interactive example of our first booklet.
|
RX SERVICES To find out more, go to
|
Next month
Another full issue, including: Zeroing in on health economics journals, 13th Annual International ISPOR meeting, Rx team profile
Previous issues
If you have missed any of our earlier issues, email duncan.dibble@ rxcomms.com for a copy. See the HOC page on the Rx website for a full list of previous articles.
HOC is available for print in pdf format – free
You can of course print this e-newsletter straight from your inbox (for best results select landscape in your printer’s print set up), but HOC is also available as a professional 4-page A4 newsletter in pdf format for you to print and keep for reference. Simply email duncan.dibble@ rxcomms.com for past copies. If you would like to be sent a pdf version each month let us know and we’ll send one as soon as it is available.
Healthcare Outcomes Communicator is designed to help you explain and enhance your role and value as healthcare economists and outcomes researchers. But we need input from you – the professionals working "in the trenches". So we encourage you to give us your feedback about how we're doing – to communicate with us so that we can better communicate with you.
Yours sincerely
David Woods and the Rx Communications team
This material is published in good faith and is subject to editorial scrutiny before publication, however no warranty or guarantee of its accuracy is expressed or implied. No liability will be accepted by Rx Communications for any loss resulting from use of this resource. Our regular readership are assured that their details will not be passed on or used in any other promotional activity without permission.
Produced by Beaumore Publishing Solutions
